The Challenge of Managing IBS in the Real World: Dogma, Dictates, Denials

The current dominant narrative of irritable bowel syndrome (IBS) is that of a non-life-threatening disorder where psychosocial factors make a larger contribution than physiological disturbances. Emphasis is placed on reassuring the patient and giving advice regard to dietary and stress management rather than taking a pharmacological approach. Yet, the published studies report subsequent excessive healthcare utilization in a setting of low investigation rates and limited pharmacological treatments [1, 2]. Is it possible that this approach is flawed? Is it possible that physiological alterations should be considered more seriously so that more patients will respond at an earlier stage of their illness, with a consequent reduction in the number of patients with severe symptoms who manifest psychological disturbances and burden emergency services?

There is evidence, albeit limited, that a more proactive approach could translate into better outcomes for patients with functional gastrointestinal disorders (FGID), a category in which IBS is included. A study from Germany [3] found that patients with functional dyspepsia managed with intensive medical diagnosis and therapy consisting of detailed diagnostic evaluation, including gastric emptying and visceral sensory function testing, followed by treatment targeted towards normalization of these functions (prokinetics in subjects with delayed gastric emptying and tricyclic antidepressants in patients with abnormal sensory function) had superior outcomes than those receiving standard medical therapy, as practised in a routine outpatient clinic setting.

In this issue of Digestive Diseases and Sciences, Koloski et al. [4], reporting from an Australian center, address the real-world challenge of managing resources expended in the care of patients with digestive diseases in the healthcare system. Of note, patients with IBS, a functional disorder, consumed substantial resources, vis-à-vis organic diagnoses such as inflammatory bowel disease (IBD) and gastroesophageal reflux disease (GERD). Although the number of diagnostic tests, procedures, gastroenterology outpatient visits, and hospitalizations were similar across the three diagnoses, IBS was overrepresented in emergency department (ED) presentations.

This pattern of excessive healthcare utilization by patients with IBS is not isolated to this Australian center. In a study of six European centers [2], the estimates of direct costs (counting hospitalizations, outpatient consultations, medications, and tests) for patients with IBS with constipation (IBS-C) were substantial. Across these six centers, within a 12-month timeframe, 11–24% of these patients accessed either ED or hospitalization care, the principal drivers of total direct costs. To identify factors that impel the need for these services, the European study recruited patients with moderate–severe symptoms, whereas the Australian study found that symptom severity was the primary determinant of healthcare utilization across the three diagnoses. The authors of the Australian study proposed that the excessive utilization of emergency services in IBS represented a failure of primary care treatment [4], alluding to the limited efficacy of pharmacological treatments while supporting lifestyle-diet interventions, basing both of these suppositions on ‘broad brushstroke’ studies. As this study did not provide the denominator of all patients treated in primary care with the specified diagnosis, there is no facility to compare the efficiency of primary care management among the three diagnoses. This study also did not provide information on the types and level of prescriptions in primary care. We as GI specialists, do not know if relevant and sufficient medications were prescribed, data that are needed before accepting the assertions that existing pharmacological treatments are ineffective and paramedical approaches are better. The costs (direct and indirect) and waiting times for dietary and psychological services need to be considered and they may not be universally available.

In the European study, prescriptions for IBS-C (laxatives, prokinetics, and anti-spasmodics) ranged from 41 to 90%, although data regarding details of drugs, dosing, and duration are lacking [2]. Nevertheless, these patients, whose overall symptom duration was over 10 years, were predominantly seen in specialist care. Thus, it is surprising that overall, only 17.5% had undergone a colonoscopy. The Rome criteria care pathway encourages a symptom-based diagnosis, hoping in so doing to reduce utilization of healthcare resources [5], although some studies suggest the contrary [1, 2].

Another study from Australia [6] identified a doctor–patient communication gap in individuals with FGID. The number of symptoms reported by patients was underestimated by 82% of gastroenterologists. Out of 40 patients, only one agreed with her physician’s diagnosis. Although substantial numbers of patients perceived diet and stress as causes of symptoms, 24% and 10% of patients, respectively, believed that infection and a weak immune system caused their problems.

Should we, as GI specialists, consider a contrarian approach? What if we send patients for detailed investigations at an earlier stage of their illness? What if primary care physicians are trained to analyze the physiological disturbances; e.g., an exaggerated gastrocolic reflex, and that there are pharmacological agents to target specific pathophysiology (e.g., anti-spasmodic)? What if we better recognize overlapping symptoms, syndromes, and pathophysiology? What if we encourage the use of treatment combinations to cover the individual patient’s spectrum of dysfunction? We have some supporting evidence for this aggressive approach from an early study prior to the advent of the Rome criteria [7], which showed a gradient of response; patients who received a combination of three active treatments improved the most, followed by combinations of two active with one placebo, and of one active with two placebos. None of the patients who received three placebos responded.

A robust prospective study (capturing factors enumerated in Table 1) should be done to challenge the current dogma.